ࡱ> ) tbjbj 44h4hOx 66666JJJ8FJ#"nK D $!#############%R(##Q6  ##66t#a"a"a" F66!#a" !#a"a"a"xH. ja" ##0#a" )c!j )a" )6a" a" ####! # ) X : AUTHORIZATION FOR EMPLOYMENT BACKGROUND CHECK Note: This form must be completed in full and signed by the Applicant. Hiring Officials must sign on their designated line and enter the correct Banner Fund. FIRSTGIVEN MIDDLEMAIDENLAST FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      All other name(s) by which you have been known: FORMTEXT      SOCIAL SECURITY #DATE OF BIRTHSEXRACE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      EMAIL ADDRESSPHONE NUMBERDRIVERS LICENSE #STATE OF ISSUANCE AND EXPIRATION DATE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Employment Type (Check One):  FORMCHECKBOX  SHRA Position  FORMCHECKBOX  EHRA Non-Faculty Position  FORMCHECKBOX  Faculty  FORMCHECKBOX  Part-Time Lecturer  FORMCHECKBOX  Temporary  FORMCHECKBOX  Student Additional Screening, as designated by the position:  FORMCHECKBOX  Credit History Check (applicable positions only, i.e. financial positions; candidate release authorization required)  FORMCHECKBOX  Statewide Motor Vehicle Check (applicable positions only, i.e. driving is a requirement or may be a requirement of the position) Have you ever been convicted of any unlawful offense, other than a minor traffic violation?  FORMCHECKBOX  YES  FORMCHECKBOX  NO Please list the street addresses of all the places you have resided over the past seven years, beginning with your current address and going backwards. DATECURRENT STREET ADDRESSCITY, STATE AND ZIP CODE FORMTEXT       FORMTEXT       FORMTEXT      DATEPREVIOUS STREET ADDRESSCITY, STATE AND ZIP CODE FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       I hereby certify that all information I have provided on this Authorization is true and complete to the best of my $&N^`     μpYYYYY,jh oh oCJOJQJUmHnHu'jh oh oCJOJQJU!jh oh oCJOJQJUh oh oCJOJQJh oh oB*phh o56B*CJaJph#h oh o56B*CJaJphh o56B*ph"h 75B*CJOJQJaJph(h oh o5B*CJOJQJaJph^` $Ifgd9 $a$gd o&$d%d&d'dNOPQgd o 2 Z d[[[[ $Ifgd9kd$$Ifl\ n(   0)4 layt o " $ & ( * , . 0 2 4 H J L N P R T V X Z \ p r t v x z | ~      ڶڶڶڶڶڶzڶ'jh oh oCJOJQJU'jh oh oCJOJQJU'jh oh oCJOJQJUh oh oCJOJQJ,jh oh oCJOJQJUmHnHu!jh oh oCJOJQJU'jh oh oCJOJQJU- bYY $Ifgd9kdq$$Ifl\ n(   0)4 layt o       $Ifgd9vkd$$Ifl0 n( 0)4 layt o      < X ` j l n ժժժ'jgh oh oCJOJQJU'jh oh oCJOJQJU,jh oh oCJOJQJUmHnHu'jh oh oCJOJQJU!jh oh oCJOJQJUh oh oCJOJQJh oh oCJOJQJ-  < X ` j bYYYY $Ifgd9kd#$$Ifl(\ n(   0)4 layt oj l d[[[[ $Ifgd9kd$$Ifl\ n(   0)4 layt o      * D h ڶm\Cmmmmmmm\0jhh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUphh oh oCJOJQJaJ%h.^h oB*CJOJQJaJph!h.^h oB*CJOJQJphh oh oCJOJQJ,jh oh oCJOJQJUmHnHu!jh oh oCJOJQJU'jh oh oCJOJQJU  * D h bYYYY $Ifgd9kdO$$Ifl\ n(   0)4 layt o  0 X bYYYY $Ifgd9kd$$Ifla\ n(   0)4 layt o      " $ & ( * , . 0 2 F H J L N P R T V X Z \ ٧َفn%h.^h oB*CJOJQJaJphh oh oCJOJQJ0j hh oB*CJOJQJUph0j hh oB*CJOJQJUph0j hh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUph#X Z \ DwxbZZZZZZZSxgd od,gd okdw $$Ifl\ n(   0)4 layt o \ )ŭoŭToŭ4j h.^hIYxB*CJOJQJUaJphhZB*CJOJQJaJph4j* h.^hIYxB*CJOJQJUaJph%h.^hIYxB*CJOJQJaJph.jh.^hIYxB*CJOJQJUaJph%h.^h oB*CJOJQJaJph%hEh oB*CJOJQJaJph(hEh o>*B*CJOJQJaJph)*+,456DEFGZ[\jklmvwyzͺͺͺͺqaQQͺh yaB*CJOJQJaJphhIYxB*CJOJQJaJph4j h.^hIYxB*CJOJQJUaJph4j h.^hIYxB*CJOJQJUaJph%h.^h oB*CJOJQJaJph%h.^hIYxB*CJOJQJaJph.jh.^hIYxB*CJOJQJUaJph4j h.^hIYxB*CJOJQJUaJphͽxxxxxxx`M%h.^h:B*CJOJQJaJph.jh.^h:B*CJOJQJUaJph"hE>*B*CJOJQJaJphhEB*CJOJQJaJph%h.^h yaB*CJOJQJaJphh yaB*CJOJQJaJphhIYxB*CJOJQJaJph.jh.^hIYxB*CJOJQJUaJph4jn h.^hIYxB*CJOJQJUaJph &(*PRSabcͽo\Ao4jVh.^h$+BB*CJOJQJUaJph%h.^h$+BB*CJOJQJaJph.jh.^h$+BB*CJOJQJUaJphh 7B*CJOJQJaJphh)A'B*CJOJQJaJph+h:h:6B*CJOJQJ]aJphh:B*CJOJQJaJph.jh.^h:B*CJOJQJUaJph4j h.^h:B*CJOJQJUaJphcq},CDERSTU\^_cmnovwx߶r\Th oCJaJ+j>hh oCJOJQJUaJ+jhh oCJOJQJUaJ%jhh oCJOJQJUaJh oCJOJQJaJhh oCJOJQJaJ%h.^h oB*CJOJQJaJph+h)A'h)A'6B*CJOJQJ]aJphh)A'B*CJOJQJaJphh$+BB*CJOJQJaJph x,EFGQRS   $&(*,.02468LNPRTVXZ\^`ҧҧҧ'jGh oh oCJOJQJU'jh oh oCJOJQJU,jh oh oCJOJQJUmHnHu'j]h oh oCJOJQJU!jh oh oCJOJQJUh oh oCJOJQJh.^h oB*CJaJph-x,EF6^bkd$$Ifl4F(J 0(    4 lalf4yt o $Ifgd9xgd o^`jriii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt o`j  468:<˺ˆ˺˺mˆ˺˺Tˆ0jhh oB*CJOJQJUph0jhh oB*CJOJQJUph5jhh oB*CJOJQJUmHnHphu0jhh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUphh oh oCJOJQJ!h.^h oB*CJOJQJph Friii $Ifgd9kdh$$Ifl4F(J 0(    4 lalf4yt o<>@BDFHJV\^`bdfhjlnprxνννν~ννe0j hh oB*CJOJQJUph0jhh oB*CJOJQJUph0j hh oB*CJOJQJUphh oh oCJOJQJ!hh oB*CJOJQJph*jhh oB*CJOJQJUph5jhh oB*CJOJQJUmHnHphu'FHpriii $Ifgd9kdu$$Ifl4F(J 0(    4 lalf4yt o   (*,.02468:<νννν~ννeν0jhh oB*CJOJQJUph0jhh oB*CJOJQJUph0j-hh oB*CJOJQJUphh oh oCJOJQJ!hh oB*CJOJQJph*jhh oB*CJOJQJUph5jhh oB*CJOJQJUmHnHphu':riii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt o:<driii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt o<>RTVXZ\^`bdfz|~٧َفh0jahh oB*CJOJQJUphh oh oCJOJQJ0j2hh oB*CJOJQJUph0jhh oB*CJOJQJUph0jHhh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUph(.riii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt o "$&(*,.02BFHJLNPRTVXZ\n٧ٚف0jzhh oB*CJOJQJUphh oh oCJOJQJ0jKhh oB*CJOJQJUph0jhh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUph,.0Xriii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt onprtvxz|~h0j hh oB*CJOJQJUph0jhh oB*CJOJQJUphh oh oCJOJQJ0jfhh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUph0jhh oB*CJOJQJUph("riii $Ifgd9kd$$Ifl4F(J 0(    4 lalf4yt o "$&:<>@BDFHJLNbdfhjlnprtvٳٚف0j&"hh oB*CJOJQJUph0j!hh oB*CJOJQJUphh oh oCJOJQJ0j hh oB*CJOJQJUph!hh oB*CJOJQJph*jhh oB*CJOJQJUph("$Ltriii $Ifgd9kd $$Ifl4F(J 0(    4 lalf4yt o  h0j$hh oB*CJOJQJUph0jA$hh oB*CJOJQJUph0j#hh oB*CJOJQJUphh oh oCJOJQJ!hh oB*CJOJQJph*jhh oB*CJOJQJUph0j"hh oB*CJOJQJUph(riii $Ifgd9kd#$$Ifl4F(J 0(    4 lalf4yt oBV\xj jkBkVk\kxkl lmBmVm\mxmn noBoVo\oxop pq,q.qBqVqXqZq\qpqrqĹ~nj%h oh6Uh oh6jh oh6Uh o6CJOJQJaJh oh o6CJOJQJaJ h oh oUh oh oCJaJh oCJaJh oh oCJOJQJ!hh oB*CJOJQJph*jhh oB*CJOJQJUph+,q.qZqqqqrkccRIRR $Ifgd P$Ifgd9$a$gd ogd okd-%$$Ifl4F(J 0(    4 lalf4yt oknowledge and belief. I hereby consent to the University s verification of any information contained in this Authorization. I understand that by admitting to a conviction for any unlawful offense, I will not be disqualified automatically from consideration for employment, but I also understand the date and nature of the crimes for which I have been convicted will be taken into consideration in the hiring process to the extent allowed by law if relevant to the position. I understand that false or misleading information or documentation, or an omission or failure to include all relevant information, may result in rejection of my application, action up to and including termination if hired, and/or criminal prosecution. If hired, I understand the University complies with State law and will terminate me if false or misleading information is given in order to meet the requirements for the position involved. Candidate s Signature  FORMTEXT      Date  FORMTEXT      Department Approval SignatureDate FORMTEXT        FORMTEXT       Department Approval Printed Name: _______________________________________________________________________ Banner Org/Fund: ___________ /Acct 22178 (Required to Process)     UNC Pembroke  Employment Background Check Form NC 65  PAGE \* MERGEFORMAT 2Revised 07.11.2022 rqtqvqxqzq|q~qqqqqqqqqqqqqqqqqqqqqqqqrr rȸwwwndh oh o6CJh oh oCJh oh o6OJQJh oh oCJ h oh oj\&h oh6Uh oh6h o6CJOJQJaJh oh o6CJOJQJaJh oh o6CJOJQJ hh+jh oh6OJQJUmHnHujh oh6U qqqqqq P$Ifgd9ckd&$$IflF&X t&    4 lalyt9 $Ifgd oqqqqr P$Ifgd9ekd\'$$IflPF&X t&    4 lalyt or r2r4r6r^r $Ifgd P$Ifgd9ckd'$$IflF&X t&    4 lalyt9 r r r"r$r&r(r*r,r.r0r2r4r6r8rLrNrPrRrTrVrXrZr\r^r`rbrxrs6s8s:sﹹﰩﹹtbbbbRh ohZ5B*CJ\ph#hyhZ5B*CJ\aJphh o5B*CJ\phh oh o6&j(h oh6OJQJUh oh o6OJQJ hhh o6OJQJ+jh oh6OJQJUmHnHu&jt(h oh6OJQJUh oh6OJQJ jh oh6OJQJU^r`rbr8s:sssssssphcYW dgd ogd o$a$gd o$&dPa$gd o $a$gd o &dPgd ockd`)$$IflF&X t&    4 lalyt9 :sBsVsXs^svsxsssssssssssttttt t ttt t.tBt~ttttttt~~p~lldld[h.^mHnHujhXUhXh 7CJ OJPJQJaJ hXCJ OJPJQJaJ h~ujh~uUh oh oCJaJh oh?f6CJaJh o6CJaJh?f6CJaJh oh o6CJaJ h oh o>*B*CJaJphh oh oB*CJaJph#h oh o5B*CJ\aJph#sttt ttt~ttttt $$Ifa$gdh/ $$Ifa$gdh/ $&d Pb$# a$ dgd o tttttttttttttth oh oCJaJh~uhXh)A'5B*phh 75B*phh:5B*phhdhX5B*ph h:7hXjhXU tttttt~gd oxkd)$$Ifl0u$ t0644 la21h:p/ =!"#$% $$If!vh#v #v #v:V l0),5 5 54ayt otDText5tDText5tDText5tDText5$$If!vh#v #v #v:V l0),5 5 54ayt ovDText22$$If!vh#v #v:V l0),5 54ayt o$$If!vh#v #v #v:V l(0)5 5 5/ 4ayt o$$If!vh#v #v #v:V l0),5 5 5/ 4ayt otDText5tDText6tDText7tDText8$$If!vh#v #v #v:V l0),5 5 54ayt o$$If!vh#v #v #v:V la0),5 5 5/ 4ayt otDText5tDText6tDText7tDText8$$If!vh#v #v #v:V l0),5 5 5/ 4ayt otDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1tDeCheck1$$Ifl!vh#v#vJ #v:V l40(,55J 54alf4yt otDText9vDText10vDText11$$Ifl!vh#v#vJ #v:V l40(,55J 54alf4yt o$$Ifl!vh#v#vJ #v:V l40(,55J 54alf4yt ovDText18vDText19vDText20$$Ifl!vh#v#vJ #v:V l40(,55J 54alf4yt ovDText18vDText19vDText20$$Ifl!vh#v#vJ #v:V l40(,55J 54alf4yt ovDText18vDText19vDText20$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt otDText9vDText10vDText11$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt otDText9vDText10vDText11$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt ovDText15vDText16vDText17$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt ovDText18vDText19vDText20$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt ovDText15vDText16vDText17$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt ovDText18vDText19vDText20$$Ifl!vh#v#vJ #v:V l40(,55J 5/ 4alf4yt ovDText36vDText37$$Ifl!vh#v#v#vX:V l t&555X/ / 4alyt9$$Ifl!vh#v#v#vX:V lP t&555X/ / 4alyt o$$Ifl!vh#v#v#vX:V l t&555X/ / 4alyt9vDText36vDText37$$Ifl!vh#v#v#vX:V l t&555X/ / 4alyt9{$$If!vh#v#v!:V l t0655x666666666vvvvvvvvv66666>666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@66666 OJPJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH hh  o Heading 2$$@&'5B*CJOJPJQJ\^JaJphOl@l  o Heading 6#$ P$d@&6CJOJPJQJ^JaJDA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List >@>  o0Header H$d..  o0 Header Char> @>  o0Footer H$d.!.  o0 Footer CharR2R  o0 Balloon Text dCJOJQJ^JaJN/AN  o0Balloon Text CharCJOJQJ^JaJVB@RV  o Body Text$da$CJOJPJQJ^JaJL/aL  oBody Text CharCJOJPJQJ^JaJ\/q\  oHeading 2 Char'5B*CJOJPJQJ\^JaJphOX@X  o Footnote Text dCJOJPJQJ^JaJT/T  oFootnote Text CharCJOJPJQJ^JaJP/P  oHeading 6 Char6CJOJPJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vj\{cp/IDg6wZ0s=Dĵw %;r,qlEآyDQ"Q,=c8B,!gxMD&铁M./SAe^QשF½|SˌDإbj|E7C<bʼNpr8fnߧFrI.{1fVԅ$21(t}kJV1/ ÚQL×07#]fVIhcMZ6/Hߏ bW`Gv Ts'BCt!LQ#JxݴyJ] C:= ċ(tRQ;^e1/-/A_Y)^6(p[_&N}njzb\->;nVb*.7p]M|MMM# ud9c47=iV7̪~㦓ødfÕ 5j z'^9J{rJЃ3Ax| FU9…i3Q/B)LʾRPx)04N O'> agYeHj*kblC=hPW!alfpX OAXl:XVZbr Zy4Sw3?WӊhPxzSq]y  EEwwwz  \ )cx`<<nrq r:stt "$&)+-/13;?AC  j X x^F:."qqr^rstt  !#%'(*,.024<=>@BD%+-9?r~\hnp|*5E[kyRbDT^nFRXZflnz  +14@FHTZ\hnq} %(4:<HNP\beqwy   & , X d j n z FFFFFFFFFFFFFG$G$G$G$G$G$G$G$G$G$F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4F4FFFFE]_z!8@0(  B S  ?Text22Text5Text6Text7Text8Check1Text36Text37sE  U - 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